This article particularly caught our attention because as
Psychiatrists we routinely prescribe psychotropic medications with
unwanted side effect in the form of weight gain. Under the Shared Care
Protocol (with General Practitioners) we often refer our patients to GPs
for weight management interventions.

Globally, there are more than 1 billion overweight adults, at least
300 million of them clinically obese. There was a marked increase in
proportion of adults that were obese between 1993 and 2012 from 13.2 % to
24.4% among men and form 16.4% to 25.1% among women1. In 2012, an
estimated 62% of adults (aged 16 and over) were overweight or obese and
2.4% had severe obesity. The prevalence of obesity rose form 15% in 1993
to 25% in 2012 2. . Data form Health Survey for England (HSE) show that
obesity rates among adults with a long- term limiting illness or
disability (LLTI) are 57% higher than adults without a LLTI. Once
considered a problem only in high-income countries, overweight and obesity
are now dramatically on the rise in low and middle income countries
particularly in urban settings.

Overweight and Obesity are major risk factors for a number of chronic
diseases including heart disease3, diabetes4, hypertension, stroke,
arthritis and cancer. The Foresight Report in 2007 estimated that direct
health care costs attributed to being overweight or obese were 4.2 billion
pounds , potentially rising to 6.3billion in 2015 and further up to 9.7
billion pounds by 20505. . A more recent analysis estimated that
overweight and obesity cost the NHS 5.1 billion pounds per year6.

The prescription of antipsychotic medication for chronic and enduring
mental illness often leads to weight gain which is most of the times an
unacceptable side effect and can also produce metabolic syndrome,
irregularities in blood level of glucose and lipids7,8. It is a delicate
balance to achieve between mental health recovery and these side effects.
These changes invariably affect the life expectancy of patients with
mental health issues9.

To effectively tackle these unwanted side effects, patients are
usually referred to dieticians and GPs for further interventions. After
reading the results that these interventions are not being offered as they
should or not recorded, it raises a few questions:

1. Every one is aware that GP surgeries are struggling to give
appointment to patients who need to be seen for their primary physical
disease. Do GP's have the flexibility or allocated time to do any type of
preventive work?

2. GP usually see their patients in 10 minutes time slots, which is
hardly sufficient to deal with the primary issue, giving prescription and
writing notes. Even though they observe that the patient is overweight
there is a limited opportunity to discuss, motivate or give proper advice
to these patients.

3. Earlier GP could prescribe exercise on prescription. In the recent
overhauling of the benefit systems, DLA has been replaced with Personal
independent Payments (PIP). Many councils have scrapped this privilege
under the assumption that people can pay to attend exercise programmes
from their PIP allowance. Under the current climate of financial
constraints, spending money on such programmes may not take precedence
over other basic needs.

Obesity is growing at a fast rate and if not tackled it would pose an
enormous economic burden on the NHS to treat various physical and mental
diseases whose precursor is obesity.

Dear Sir,
I read this article with great interest as it resonate all the research
work done in addiction psychiatry in developed countries. As
Psychiatrists we come across many services user whose mental illness is
complicated with various substances harmful use or dependency.

Drug addiction is a big problem world wide especially addiction to
class A substance which is difficult to overcome without expert help.It
is estimated that there are 500,000 heroin addict in USA and Public Health
England figures state that there are around 262,000 opiate drug user in
England in 2010/11. The latest figures does show that the drug addiction
is more in older group (25-35 years) rather than early teens or young
adults1. Not to forget, three times or more the number of these figure ,
the carers and the family members effected by drug addiction problem of
their loved one. Unfortunate there is a large proportion of children who
are deprived of stable family homes and are ofter under the care of social
services2. These children are more vulnerable to mental health problems
including attachment disorder, depression, anxiety ,bullying and
predisposition to substance addiction.

The burden on any health economy due to drug addiction is massive ,
its impact on mental health and direct consequences on physical health,
there are many other blood borne and sexually transmitted disease which
are more prevalent in drug addicts e.g. Hepatitis B and C and HIV. 120
new cases of HIV ,in 2012 ,were infection acquired through injecting
drugs3.There were 6,549 admissions to mental health hospital with a
primary diagnosis of a drug-related mental health and behavioural disorder
in 2012/134.

To fund their drug habit , the drug users do various crimes from
shoplifting, burglary, theft selling or smuggling drugs and prostitution5.
This adds huge burden Criminal Justice System.The problem drug use costs
society ?15.4 billion a year, of which ?13.9 billion is attributed to
crime committed by drug dependent offenders5 . Government spending on
drug treatment give good value for money, for every one pound , it
generates 2.50 pounds worth of savings6.

Methadone replacement treatment for opiate dependency has been
practiced in developed countries for more than two decades. Research has
shown that it is cost effective in the term of harm reduction .Its long
half life not only helps in combating opioid withdrawal symptoms but it
also reduces cravings for opioids.It reduced the euphoric effect of
heroine. A number of studies have shown that Methadone maintenance
treatment is associated with reduction in mortality (accidental
overdoses), injection practices, blood borne infections and other sexually
transmitted diseases and criminality. It also improves physical &
mental health, social functioning and quality of life6. There is
significant reduction in crime rate after the service user enters
methadone treatment programme7,8.

For all these above reasons it is important that Methadone treatment
should be the part of a comprehensive assessment which not only for harm
reduction but also encourages, as we say each contact matters, service
user for detox and rehabilitation.

Lawyers think in terms of crime, homicide with or without
premeditation, fraud, legal responsibility, economic damage,
indemnification and guilt. Terms medical doctors are not so familiar with.
Medical doctors think in terms of patients, differential diagnosis,
treatment options, cure and care.
Because the primary aim of practising medicine is to help patients, we are
particularly affected if something goes wrong, especially if this results
in harm to our patient. Medical doctors are human beings. We may misjudge
a situation, underestimate a disease's severity or be misled by the
patient's history. Because unintentional inappropriate medical acts may
have serious or fatal consequences, it is of paramount importance that we
learn from errors and complications. The history of medicine has been
written this way. Progress in medicine is based on (self)reflection each
time things didn't turn out as expected.
The paper by Tom Bourne et al.(1) demonstrates that complaints procedures
may hinder this permanent evaluation and improvement process, and may have
an adverse effect on patients' safety. The paper doesn't plead for a
permissive policy of low level medical practice. On the contrary, it is
acknowledged that in order to reach the medical care levels of excellence
patients are entitled to, each unexpected adverse outcome should be
debriefed.
This paper is particularly important because scientific evidence is given
that complaints procedures can have disastrous side effects on medical
doctor's psychological health, and hence can change the attitude of the
entire medical profession.
Customers are instructed not to talk to the driver while the bus is in
motion, to avoid accidents because distraction may compromise the
customers' safety. Bus companies do not expect their drivers to be
'emotionally resilient' (2) enough to cope with distraction.
Likewise, the primary goal of medical councils is to guarantee a safe and
"distraction free" working environment for medical doctors, allowing good
medical practice and ensuring patients' safety. Tom Bourne's study
demonstrates complaints procedures may become a 'fatal distraction' for
the medical practise. It is doubtful if the introduction of 'emotional
resilience' training (2) for medical doctors is the appropriate answer.

We would like to thank Niall Dickson for his interest in our paper
(1). As Dickson suggests, being the subject of an investigation in any
profession is likely to be associated with stress and anxiety. Professor
Terence Stephenson illustrated the scale of the problem in medicine when
he stated in his recent evidence to the health select committee "I have
personally been investigated twice by the GMC. Doctors recognize having
complaints against them as an occupational hazard" (2). The implication
being that the regulator expects most doctors to be subject to a General
Medical Council (GMC) referral at some stage of their career. Set against
this, whilst some distress is inevitable, we would contend that levels of
moderate to severe depression of over 25%, moderate to severe anxiety of
22%, and suicidal ideation of 16% associated with being investigated by a
regulator or indeed any other body is not acceptable in any profession.

To better put this in context it is perhaps helpful to review some
definitions to better understand the seriousness of this issue. Moderate
depression is defined by persistent low mood or irritability and a loss of
interest in usual activities. Other symptoms include slowed thinking,
difficulty remembering things or making decisions, loss of energy and
decreased activity levels, low self esteem, guilt and self-blame,
disrupted sleep and frequent thoughts of death and suicidal thoughts. The
severity of the depression refers to the number of symptoms present as
well as the degree of impairment to daily functioning across several life
domains, such as relationships and work (3). Such a combination of
symptoms will have a baleful impact on an individual and be highly likely
to impair their function as a clinician. It does not seem reasonable that
such a profound impact on an individual's mental health is an acceptable
cost of a regulatory process. In any event our paper and others can now
leave both the GMC and others involved in complaints investigations in no
doubt that their procedures may be associated with serious psychological
morbidity.

Dickson also cites a comment made by Professor Terence Stephenson to
the health select committee about defensive practice, suggesting doctors
are more concerned about the media and litigation than other types of
investigation (2). We are not aware of any data to substantiate this view.
In any event our paper concerned itself with reported defensive practice
by doctors experiencing complaints processes or their views having
observed others go through them. As the overall level of defensive
practice was around 80%, levels of defensive practice associated with
media exposure or litigation must be very high indeed. The levels of
avoidance behavior reported by doctors involved in GMC processes (46%),
and of doctors reporting that they had suggested invasive procedures
against their professional judgment (26%), are a real concern. We would
take the view that the relationship between complaints
processes/regulation, the impact of defensive practice, and overall
patient safety merits further research.

Dickson is right to point out that the GMC is only one part of a
system that deals with complaints that we have called the "complaints
pyramid". Our paper shows that significant psychological distress is
associated with all types of complaint process, as is defensive practice
in response to complaints. In 2013-14 in England there were over 175,000
written complaints with more than 52,000 directed towards medical staff
(4). Given the vast workload that must be involved in dealing with these
and the distress to staff associated with them, it would seem important
that complaints processes are reviewed across the board. In his letter
Dickson touches on changes in the operations of the GMC that will
fundamentally change the relationship between the regulator and doctors,
many of which are contained within a recent consultation document (5).
Serious concerns have been raised about many of these proposals (6), in
particular in the context of this discussion, the stated desire of the GMC
to investigate and/or impose sanctions without regard to the personal
impact these may have on doctors.

Our study summarises what doctors who took part thought would improve
things. In order of importance these were: complete transparency about any
communications and documentation, those responsible for handling
complaints should have a full and up to date knowledge of correct
procedure, action should be taken against complainants in the event that a
complaint has been shown to be vexatious, if a doctor is exonerated there
should be a mechanism to recover costs, there should be a strict time
limit within which complaints must be submitted and that multiple
complaints to different authorities should not be permitted, and finally a
complaints process must have a statutory limit to the time taken to carry
out any investigation. These can all be reviewed in supplementary online
table 5 in our paper (1). When considering the balance that is required
between investigating complaints appropriately whilst having a fair open
system for doctors, none of the proposals listed above seem either
unreasonable or undeliverable.

A major problem with clinical complaints is that the GMC deals with
individuals and is not equipped to deal with the cause of most clinical
errors - the system in place on the day the error took place. Accordingly
whilst the GMC sets out to protect the public, the reality is that it can
only address one part of what is often a larger problem. An example might
be the current controversy over A&E waiting times. There seems to be a
consensus that there are issues relating to volumes of patients and
staffing. Accordingly doctors in these hard pressed A&E departments are
working under pressure, they may be cutting corners to cope, or simply not
have the time to do things properly, it is likely they will fail to
communicate as well as they would like with patients. They will be the
individuals reported to the GMC when something goes wrong, not trust
managers or people in the department of health. The only fair way to
investigate complaints in this situation it to look at the overall set of
circumstances a doctor has been placed in, if anything is going to be
learnt from what has gone wrong. It is therefore axiomatic that the GMC is
not the right body to be examining such clinical complaints. These should
be investigated locally or by another external body with a much broader
remit. The proposal outlined by the chair of the public administration
select committee in the UK is based on a review by Macrae and Vincent (7),
and seems a good starting point for this discussion. The principal
proposals for such an investigative body are that it should be:

* Transparent. Clear, timely, open communication of findings of
investigations, recommendations and monitoring of implementation.

* Established as permanent body able to investigate and follow up
recommendations over years.

* Collaborative and cooperative. Working in partnership with those
being investigated.

* Authority to access all sites, organisations, staff and information
across the healthcare system.

* Non-punitive. Separated from assignment of blame or liability and
legally protected.

* Accountable.

Further to these proposals based on the feedback received in our
study we would also suggest that when investigating complaints:

* It is clearly set out what is and is not within the remit of
investigation locally, by a national clinical complaints body and what
should be looked at by the GMC. There should be no double or triple
jeopardy as exists currently with the potential for doctors or clinical
errors to be investigated serially or in parallel by different bodies.

* Enforce a strict time limit that is permitted for any complaints
process and resource it appropriately.

* The source of any vexatious complaints should be investigated and
disciplinary action taken in the event of it being a staff member or
redress in the courts if from a patient as there is no public interest
defense in the event of a complaint being shown to be vexatious.

Currently as alluded to above, in the UK we have the public
administration select committee taking evidence on the handling of
complaints. The health select committee has just had its accountability
hearing with the GMC where complaints were discussed. Lord Robert Frances
is leading a review of whistleblowing in relation to complaints, and the
GMC has also asked Sir Anthony Hooper to report on whistleblowing in a
separate piece of work. In every clinical environment we see information
about how to complain, and entering "NHS complaints" into a Google search
leads to a plethora of sponsored sites from solicitors. The GMC is asking
for more powers. In parallel to this we have seen the introduction of
revalidation. We have also seen the rise in patient "opinion" as a major
part of how services are rated, despite emerging evidence that levels of
patient satisfaction are not necessarily associated with the quality of
their care (8,9). Furthermore turning each hospital interaction into a
"customer service experience" requiring feedback may be intrusive in
itself (10). Given this extraordinary level of activity, it is surely
reasonable to ask where the evidence is from good quality appropriately
analysed studies to show all these interventions are leading to
improvements in patient care? In clinical medicine we are expected to
practice evidence-based medicine, we carry out systematic reviews based on
standardized measures of evidence quality (11). We defer to the opinion of
the National Institute for Health and Care Excellence (NICE) on the cost
effectiveness and efficacy of interventions. Perhaps it is now time for
NICE to start reviewing regulatory interventions and for us to demand
evidence of value and patient benefit from properly conducted pilot trials
before they are implemented more widely?

An example of such an intervention might be resilience training. This
possibility was raised at the recent health select committee GMC
accountability hearing as a possible solution to doctors suffering mental
ill health associated with complaints processes (2). Probably the largest
example of resilience training is the comprehensive soldier and family
fitness program in the United States army, also known as CSF2. However the
value of this training in the military is questioned by some authors (12),
and it was recently stated in JAMA that the CSF2 has shown only small
effects in preventing PTSD and depression despite the department of
defense investing over $125 million in expanding the program (13). On the
other hand there are some emerging data on the benefits of mindfulness and
self-compassion on other aspects of doctors behaviour (14,15), and whilst
such programs are unlikely to be harmful, it is premature to estimate how
efficacious they will be in preventing depression and anxiety in the
context of complaints. In any event, whilst resilience training tends to
focus on building an individuals coping and stress management reservoir,
resilience should be a multi-faceted construct that depends on having a
positive work environment and flexible working conditions as well as good
leadership.

It is important to acknowledge that the position of the GMC is very
difficult. Understandably following such extreme and rare events as the
Shipman case, there were calls for more regulation. In parallel to this
our paper and others demonstrate that doctors respond to fears about the
fairness and outcomes of all types or complaints processes, including
those of the GMC, by practicing defensively themselves. We would suggest
that neither of these behaviors are in the best interest of patients and
perhaps now is the time to take a step back and break this cycle by
reviewing how complaints are best managed in the NHS. In order to do this
all parties should remember two key points from the Berwick report (16).
Firstly "fear is toxic to both safety and improvement", and secondly
"supervisory and regulatory systems should be simple and clear, avoid
diffusion of responsibility, and be respectful of the goodwill and sound
intention of the vast majority of staff".

4. Health and Social care Information Centre. Data on Written
Complaints in the NHS - 2013-14 [NS]. Publication date: August 28, 2014
http://www.hscic.gov.uk/catalogue/PUB14705 Last accessed 26th January 2015

5. GMC consultation: Reviewing how we deal with concerns about
doctors - A public consultation on changes to our sanctions guidance and
on the role of apologies and warnings.
https://gmc.econsultation.net/econsult/consultation_Dtl.aspx?consult_Id=...
(last accessed 28th September 2014)

6. Jalmbrant M. The GMC consultation on regulation suggests the
regulator has ambitions to be a punitive body based on "maintaining public
confidence", whilst the proposed regulatory changes may harm doctors and
patient care.
BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g5744 (Published 25
September 2014)

16. Berwick review into patient safety. A promise to learn - a
commitment to act: improving the safety of patients in England. Department
of Health.
https://www.gov.uk/government/publications/berwick-review-into-patient-
safety
Last accessed 25th January 2015

I read this article with great interest and applaud the efforts of
the authors to highlight what would seem obvious mental health
consequences of such traumatic events as investigations can be for
doctors, yet the consequences can be so easily overseen.

As Psychiatrists we come across individuals in our practice
traumatised by various significant life events which have consequences on
their mental health both in the short and long term.

For a doctor who undergoes any investigation be it informal or
formal, by employers or regulating bodies like the GMC, the process can be
life changing and can have long ranging impacts not only on the individual
but also their near and dear ones.

The reasons for the manner in which a matter is dealt with can be
multi factorial, but the fact remains that the individual has to endure
and cope with whatever follows.

The tendency for practical ex communication of the individual in the
event of and during an investigation can only magnify the severity of the
impact on the individual's mental health.

The ignominy and stigmatisation that subsequently follows can
contribute to isolation and potentially even lead to maladaptive coping
strategies such as alcohol or substance misuse.

The potential for contemplating self-harm and potentially even
suicide or death is a fact which is reflected in various statistics quoted
in the paper.

The manner in which issues like this are highlighted therefore need
to be considered in great depth and through great reflection.

The support systems made available to doctors who are undergoing
investigations, may also possibly need to identify ways of reinforcing
existing support networks and acknowledging the impact on the individuals
family, who may also potentially need supporting. More so in those cases
where the individual may not have any extended family in this country , as
the numbers highlight, there are many who may be single and from countries
apart from the UK.

Cases often attract media attention, often splashed onto the internet
as newsworthy, but remain on the internet even when the matter is closed.
This can be detrimental on the individual and their families for posterity
as there may be no way of having these so called 'newsworthy' items
removed from the domain of the overly accessible internet led media of
modern global age.

It is commendable that the GMC is acknowledging and taking steps to
sensitively deal with the matters especially in the manner of
communications to doctors under investigation , but that still does not
and cannot possibly take away the stress the doctor under investigation
must endure .

The consequences and potential impact on the individuals mental
health has to be given due relevance and importance , as these situations
can be hypothetically equated to conditions which could lead to anxiety
related conditions even with shades of Post-Traumatic Stress Disorder and
major mood disorders. These enduring mental health conditions unless
appropriately addressed can potentially outlast the investigation.

Which unless acknowledged and treated appropriately, could, have an
impact not only on subsequent medical practice but also on in a holistic
sense, on the remainder of the individual's lifetime.

It has been recently observed that mortality in general and for
cardio-vascular conditions specifically follows a pattern of high and low
years (1-2). Had this study used 1999 as the base year the calculated
reduction would have bee higher. Likewise had they used 2003 as the end
point the calculated reduction would have been lower.

2. Jones R. Recurring Outbreaks of an Infection Apparently Targeting
Immune Function, and Consequent Unprecedented Growth in Medical Admission
and Costs in the United Kingdom: A Review. British Journal of Medicine and
Medical Research 2015; 6(8): 735-770.

That Mr Dickson's has responded to Bourne's paper is highly
significant and possibly the first clear acknowledgement from a senior GMC
figure that its processes are associated with stress and anxiety, and that
there is "much still for us [the GMC] still to do".

It seems to me and others that we owe it to all involved in this
debate to move forward in a positive way that will both ensure patient
safety and carry the confidence of the profession. This would without
doubt as a prerequisite require some form of public or judicial inquiry
into the effect of GMC processes on doctors, their practice and health,
and on their deaths and suicides whilst under investigation. Further, to
examine the unintended consequences on patient care of an adversarial,
expensive, protracted quasi-criminal investigative system that was
designed in 1858 to investigate Professional Conduct.

And finally, in this vexed time of CQC and GMC hyper-activity, to
take a measured approach to how we would want healthcare in its broadest
sense to be investigated and regulated in the future. This would be most
successfully achieved if doctors looked forward with the anticipation of
learning and improving following adverse events and complaints, rather
than for fear of losing their professional reputations and livelihoods.

Conflict of Interest:

I have an interest in medical regulation, have been a formal and informal mentor to those undergoing disciplinary processes,
past LNC Chair

Anyone who has been the subject of an investigation in any profession
will testify to the stress and anxiety that it engenders. This was
underlined in the study by Bourne et al in BMJ Open, which looked at the
responses from nearly 8000 doctors who had been investigated by various
organisations, the vast majority by local NHS bodies.

Unsurprisingly the study found that among the 374 doctors who
responded to the survey who had been referred to the GMC (1), levels of
stress were higher - a referral to the national regulator is often more
serious and, of course, carries with it the additional (albeit extremely
small) risk that their livelihood could be taken away.

Some distress is therefore inevitable, but the onus is on us to do
whatever we can to reduce the fear and upset doctors experience, without
in any way compromising our duty to investigate thoroughly in order to
protect patient safety. This has become even more important in recent
years as the number of doctors referred to the GMC has risen year after
year - we saw a 64% rise between 2010 and 2013. (2) It is of course part
of a wider trend which has seen big increases in complaints against
health, and indeed other professionals, not just in this country but
around the world. (3) But it does merit a response.

Most of the complaints we receive are closed without a doctor ever
facing action and only a small proportion lead to a sanction. (4) The
increase in referrals though, makes it more important than ever that we
resolve complaints as quickly as possible, sorting out those which are
serious and which need our attention, explain our processes and decisions
clearly and provide support for doctors during what will always be a very
difficult time.

That is why, over the last few years, we have committed ourselves to
fundamental reform of our procedures with the aims of doing everything we
can to demonstrate the system is fair, speed up the process at every stage
and provide support in various ways for both doctors and patients who find
themselves involved in our investigations.

As a result, we established the autonomous Medical Practitioners
Tribunal Service (MPTS) in 2012 under the leadership of a former deputy
High Court judge which is now responsible for all the hearings and is
separate from the GMC's investigation arm.(5)

The new service has already cut the time lost to legal argument at
this stage and, subject to parliamentary approval of changes of the
Medical Act, will soon have more powers to prevent delays. (6) It has
also begun to offer more support to unrepresented doctors. (7)

Since 2012 the GMC itself has funded a confidential advice service
run by the BMA which provides emotional support for any doctor who is
being investigated by us. The response to the Doctors for Doctors service
has been overwhelmingly positive and an independent evaluation which we
will be publishing soon found that the service delivered real benefits to
the doctors who used it. As one doctor noted:

'It helped more than I could ever have imagined.'

We have had a similar reaction to another key reform in this area. We
have begun to pilot meetings with doctors towards the end of our
investigations with the aim of seeing if we can we can agree a resolution
that will protect the public and the reputation of the profession, but
which could avoid the need for a hearing altogether. (8) This has the dual
advantage of speeding up the process and reducing the stress for all
involved. Under the current law we can only do this with some cases (the
most serious must go to a hearing) but again the response has been
extremely positive.

Alongside these changes, we have been improving the tone of our
communications with doctors - we need to make sure everything we send out
is clear, straightforward and sensitive. We have been working with
doctors who have been through our procedures and we are acting on this
feedback (9) not least in updating doctors about the progress of our
investigation.

We have also revolutionised the way we engage at a local level,
communicating with employers and doctors through face-to-face meetings and
not just via correspondence. Our Employer Liaison Service (ELS) in
particular has created strong links with employers and now supports
Responsible Officers in managing concerns locally, helping to make sure
that doctors are only referred to us when it is necessary.

The Bourne study suggests that complaints may foster defensive
medicine that is not in the interests of patients - clearly anyone who has
been referred to the GMC may be more cautious while the issue is being
investigated, but as the Chair of the GMC Professor Terence Stephenson
indicated in his response to the Health Select Committee earlier this
month, medicine has perhaps become more defensive and this is likely to
have been caused more by fear of litigation, complaints to employers and
being vilified, often unfairly, in the media, rather than fear of being
referred to the GMC. (10)

Most serious complaints that are upheld in our procedures are about
conduct and health, rather than clinical decisions (11) and it is worth
remembering that we will only take action when there have been serious or
persistent breaches to our guidance - the vast majority of one off
clinical mistakes are not matters we will pursue.

So there is much we have done and there is much still for us still to
do in this area - for example we have agreed to undertake a comprehensive
review of how we handle vulnerable doctors following the report we
commissioned into doctors who commit suicide in our procedures. (12)

At the same time, creating a quick and simple complaints process that
puts patients first, and is fair to those who are complained about, must
be a matter for the health system as a whole. It is not something that
professional regulation can achieve alone, indeed as the BMJ Open paper
acknowledges, we are just one part of a much larger picture.

Dear Authors, Congratulations for the great work.
For a long time, doctors have been put in the dock for minor offences,
including some non-offences, like illnesses mostly mental health and
alcohol etc substance misuse related.

The procedures applied by the GMC, after a complaint, Interim
conditions or suspensions are placed by the panels, which convene upto six
times in the first eighteen months period. At the end of this period, many
doctors are being offered 'Voluntary Undertakings'(most doctors do not
refuse for fear of referral to the Fitness To Practice). This pathways is
highly questionable on moral and ethical grounds, as the doctor is
persuaded to accept when there has been no findings of fact made against
him.

If and when the conditions and Undertakings make the doctor
unemployable, the deskilled doctor cannot find support for retraining.

Warnings by the GMC for minor dismeanours are affecting career and
work prospects of doctors, which in some cases cause irreversible damage.

The GMC has to use Occupational health procedures in sick doctors
affairs instead of using the Fitness To Practice procedures, which are
causing untold suffering and in some tragic cases, deaths.

The deaths are only a tip of the iceberg, as most of the damage
cannot be quantified, as it is manifested in loss of work of the doctors,
emigration, burnout, early retirement.

There needs steps taken by the Government to stem this unnecessary
steady erosion of morale and the work force.
I suggest

1. A work force and planning body, independent of the NHS and the GMC
2. GMC to assess the impact of the procedures, more thoroughly, especially
on the subgroups of Mentally/physically ill doctors and Ethnic and foreign
gradute doctors
3. Use Occupational health supportive route in the sick/vulnerable doctors
instead of the disciplinary route.
4. GMC to give 'advisory' letters instead of 'warnings'.
5. Government,NHS and the GMC to launch a fund for retraining of the
deskilled doctors.
6. Fitness To Practice procedures to be used only in exceptional
circumstances, unlike now.
7. Investigation into the lack of legal representation in upto half of the
GMC hearings.
8. Making the GMC procedures accountable with compensation for the loss of
earnings and careers of the doctors who are exonerated after prolonged, in
some cases upto half a decade or more.